Provider Demographics
NPI:1770671612
Name:JACOB, ANITA JOY (MS)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:JOY
Last Name:JACOB
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27001 LA PAZ RD STE 403
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5529
Mailing Address - Country:US
Mailing Address - Phone:949-306-1512
Mailing Address - Fax:
Practice Address - Street 1:27001 LA PAZ RD STE 403
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5529
Practice Address - Country:US
Practice Address - Phone:949-306-1512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 43525106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC 43525OtherTHERAPIST